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The peritoneal cancer index as a predictor of complete cytoreduction at primary and interval cytoreductive surgery in advanced ovarian cancer
  1. Paula J Fagan1,2,
  2. Nana Gomes1,3,
  3. Owen M Heath1,
  4. Dhivya Chandrasekaran1,4,
  5. Shih-Ern Yao5,
  6. Laura Satchwell1,
  7. Angela George1,3,
  8. Susana Banerjee1,3,
  9. Aslam Sohaib1,
  10. Desmond P Barton1,2,
  11. Marielle Nobbenhuis1,
  12. Thomas Ind1,6 and
  13. John Butler1
  1. 1 Department of Gynaecological Oncology, The Royal Marsden NHS Foundation Trust, London, UK
  2. 2 Gynaecological Cancer Unit, St George's University Hospitals NHS Foundation Trust, London, UK
  3. 3 The Institute of Cancer Research (ICR), London, UK
  4. 4 Department of Gynaecological Oncology, University College London Hospitals NHS Foundation Trust, London, UK
  5. 5 Department of Gynaecological Oncology, Monash Cancer Centre, Bentleigh East, Victoria, Australia
  6. 6 St George’s University of London, London, UK
  1. Correspondence to Dr Paula J Fagan, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK; paulafagan{at}


Objective The peritoneal cancer index quantitatively assesses cancer distribution and tumor burden in the peritoneal cavity. The aim of this study is to evaluate the association between the peritoneal cancer index and completeness of surgical cytoreduction for ovarian cancer and to identify a cut-off above which complete cytoreduction is unlikely.

Methods This is a single-center prospective cohort observational study. A total of 100 consecutive patients who underwent ovarian cancer surgery were included. Peritoneal cancer index scores prior to and after surgery were calculated, and a cut-off value for incomplete cytoreduction was identified using a receiver operator characteristic (ROC) curve. Surgical complexity, blood loss, length of surgery, and complications were analyzed and associations with the peritoneal cancer index score were evaluated.

Results The overall median peritoneal cancer index score was 9.5 (range 0–36). The median age of the patients was 61 years (range 24–85). The most common stage was III (13% stage II, 53% stage III, 34% stage IV) and the most common histologic sub-type was high-grade serous (76% high-grade serous, 8% low-grade serous, 5% clear cell, 4% serous borderline, 2% endometrioid, 2% adult granulosa cell, 2% adenocarcinoma, 1% carcinosarcoma). Complete cytoreduction was achieved in 82% of patients, with a median score of 9 (range 0–30). The remaining 18% had a median score of 28.5 (range 0–36). The best predictor of incomplete cytoreduction was the peritoneal cancer index score, with an area under the curve (AUC) of 0.928 (95% CI 0.85 to 1.00). ROC curve analysis determined a peritoneal cancer index cut-off score of 20. Major complications occurred in 15% of patients with peritoneal cancer index scores >20 and in 2.5% of patients with scores ≤20, which was statistically significant (p=0.014).

Conclusions In our study we found that a peritoneal cancer index score of ≤20 was associated with a high likelihood of complete cytoreduction. Incorporating the peritoneal cancer index into routine surgical practice and research may impact treatment plans.

  • ovarian cancer
  • peritoneal cavity
  • surgical oncology
  • postoperative complications
  • cytoreduction surgical procedures

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Contributors JB is the guarantor of the article. JB and PJF designed the study, collected, analyzed and interpreted the data. PJF wrote the final manuscript. NG, OH, DC and S-EY collected data and supported the writing of the manuscript. LS and PJF performed the statistical analyses, interpreted the results in the context of the study and wrote the statistics sections of the manuscript. AG and SB provided medical oncology input for conceptualizing the study and interpreting the results. AS provided radiological input for conceptualizing the study and interpreting the results. DB, MN, TI and JB performed the operations, collected intra-operative data and supervised the project. All authors discussed the results and commented on the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.